Citation Nr: 9825884
Decision Date: 08/28/98 Archive Date: 07/27/01
DOCKET NO. 95-41 171 ) DATE
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On appeal from the
Department of Veterans Affairs Regional Office in
Albuquerque, New Mexico
THE ISSUE
Entitlement to an increased rating for post-traumatic stress
disorder, currently evaluated as 30 percent disabling.
REPRESENTATION
Appellant represented by: Disabled American Veterans
ATTORNEY FOR THE BOARD
R. M. Yonemoto, Counsel
REMAND
The veteran had active service from April 1968 to April 1971.
He argues that he should be entitled to a disability rating
higher than that currently in effect for his service-
connected post-traumatic stress disorder.
In a letter of December 1994, a team leader from the Vet
Center related that the veteran had first been seen in late
1986 and had continuously been a client since then, and that
the veteran had been seen by either a Vet Center personnel or
a contract counselor with Zia Consultants. In November 1995,
the veteran added that he had been receiving treatment at the
Vet Center since 1987 and under contract with Zia since 1993,
and that it did not appear that his entire psychiatric
records were in the claims folders for review. Currently, it
does not appear that the clinical records showing treatment
of the veteran them are on file.
In an undated statement, received in August 1995, M.
Westbrook, Ph.D., related that the veteran had worked only
part-time on an irregular basis for the previous eight years.
She recommended that any employment information on the
veteran should be obtained directly from his employer.
Subsequently, in August 1995, the veteran stated that he had
not worked regularly since 1979. No follow-up information
was obtained from the veteran's employer.
The veteran was accorded a Department of Veterans Affair (VA)
psychiatric examination in September 1996. Clinical data
disclosed that he was involved in a serious motorcycle
accident in February 1996, and that the veteran had been
employed as a machinist, but since his accident he had not
been able to work. The diagnosis was post-traumatic stress
disorder, exacerbation due to current stressors and leg
amputation.
In April 1997, the veteran had a special VA psychiatric
examination. On that occasion, the examiner reported the
veteran's claims folders were not available. Moreover, the
examiner indicated that there might be the possibility of
missing examination reports of 1995 and 1996. In order for
an examination to be considered adequate, the veteran's
claims folders together with all examination reports should
be reviewed by the examiner. The Board of Veterans' Appeals
(Board) also observes that the supplemental statements of the
case, dated in June and October 1997, contain no reference to
the April 1997 psychiatric examination report.
On file is a letter, dated in January 1998, from the veteran
who reported receiving Social Security benefits.
In view of the forgoing and in an effort to afford the
veteran every administrative consideration in connection with
his claim, the case is REMANDED for the following actions:
1. The Regional Office (RO) should
request that the veteran provide names,
addresses, and approximate dates of
treatment from all VA and non-VA health
care providers, not already of record,
who have treated him for a psychiatric
disorder since 1986. The RO should also
attempt to obtain and associate with the
claims folders copies of his medical and
clinical notes and reports, showing
psychiatric treatment generated or
submitted in connection with the
veteran's application for Social Security
Benefits. Also, the treatment records
from the Vet Center and Zia Consultants
should be included in the claims folders.
With any necessary authorization from the
veteran, the RO should attempt to obtain
copies of pertinent treatment records
identified by the veteran in response to
this request, which have not been
previously secured and associated with
his claims folders.
2. The RO should ensure that all
examination reports referenced by the
examiner in April 1997 be made part of
the veteran's claims folders.
3. A social and industrial survey should
be undertaken by the VA in order to
determine the veteran's occupational
training, employment history, social
activities, and the effect of his
service-connected disabilities upon daily
functioning. A written copy of the
report should be associated with the
veteran's claims folders.
4. Upon receipt of the above requested
documents, the RO should schedule the
veteran for a special VA psychiatric
examination to determine the extent and
severity the veteran's post-traumatic
stress disorder. The veteran's claims
folders should be provided to the
examining physician for review, and the
examining physician should so note in the
examination report. The examiner should
identify all of the veteran's psychiatric
symptomatology in order to determine the
impairment caused by post-traumatic
stress disorder. During the course of
the examination, the examiner should
identify all of the symptoms or
manifestations of the veteran's service-
connected post-traumatic stress disorder.
If there are other psychiatric conditions
found, in addition to post-traumatic
stress disorder, the examiner should
specify which symptoms are associated
with each particular disorder. If
certain symptomatology cannot be
dissociated from one disorder or another,
it should be so indicated. A multi-axial
assessment should be conducted, and a
thorough discussion of Axis IV
(psychosocial and environmental problems)
and Axis V (GAF score), with an
explanation of the numeric code assigned,
is to be included. The rationale for all
conclusions and opinions are to be noted
on the examination report, which should
be associated with the veteran's claims
folders.
5. After undertaking any development
deemed appropriate in addition to that
specified above, the RO should
readjudicate the issue of entitlement to
an increased rating for post-traumatic
stress disorder.
If the matter is not resolved to the veteran's satisfaction,
a supplemental statement of the case should be issued and the
veteran and his representative afforded an opportunity to
respond. The case should then be returned to the Board for
further appellate review, if otherwise in order. In taking
this action, the Board implies no conclusion, either legal or
factual, as to any final outcome warranted. No action is
required of the veteran until he is otherwise notified.
This claim must be afforded expeditious treatment by the RO.
The law requires that all claims that are remanded by the
Board of Veterans' Appeals (Board) or by the United States
Court of Veterans Appeals (Court) for additional development
or other appropriate action must be handled in an expeditious
manner. See The Veterans' Benefits Improvements Act of 1994,
Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994),
38 U.S.C.A. § 5101 (West Supp. 1998) (Historical and
Statutory Notes). In addition, VBA's ADJUDICATION PROCEDURE
MANUAL, M21-1, Part IV, directs the ROs to provide
expeditious handling of all cases that have been remanded by
the Board and the Court. See M21-1, Part IV, paras. 8.44-
8.45 and 38.02-38.03.
Barry F. Bohan
Member, Board of Veterans' Appeals
Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the
Board is appealable to the Court. This Remand is in the
nature of a preliminary order and does not constitute a
decision of the Board on the merits of your appeal.
38 C.F.R. § 20.1100(b) (1997).